2012-261-3-Grad Staff Interim Brochure-v3 Layout 1 … · A $10 Copay for generic and $20 Copay for brand name applies to each covered prescription filled at the Purdue Pharmacy

West Lafayette, Indiana

12-BR-IN

STUDENT INJURY AND SICKNESSINSURANCE PLAN

2012-2013

Designed Especially for the Graduate Student Staff of

13-261-3

Important: Please see the Notice on the first page of thisplan material concerning student health insurance coverage.

Notice Regarding Your Student Health Insurance Coverage

Your student health insurance coverage, offered byUnitedHealthcare Insurance Company, may not meet theminimum standards required by the health care reform lawfor restrictions on annual dollar limits. The annual dollarlimits ensure that consumers have sufficient access tomedical benefits throughout the annual term of the policy.Restrictions for annual dollar limits for group and individualhealth insurance coverage are $1.25 million for policyyears before September 23, 2012; and $2 million for policyyears beginning on or after September 23, 2012 but beforeJanuary 1, 2014. Restrictions on annual dollar limits forstudent health insurance coverage are $100,000 for policyyears before September 23, 2012 and $500,000 for policyyears beginning on or after September 23, 2012 but beforeJanuary 1, 2014. Your student health insurance coverageputs a policy year limit of $1,000,000 for each Injury orSicknessthat applies to the essential benefits provided inthe Schedule of Benefits unless otherwise specified. If youhave any questions or concerns about this notice, contactCustomer Service at 1-888-224-4754. Be advised that youmay be eligible for coverage under a group health plan ofa parent's employer or under a parent's individual healthinsurance policy if you are under the age of 26. Contact theplan administrator of the parent's employer plan or theparent's individual health insurance issuer for moreinformation.

Table of Contents

Notice Regarding Your Student Health Insurance Coverage . . . . . . . . . . . . . . . . . . . . . . . . .2Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Effective and Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Annual Premium Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Extension of Benefits after Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Purdue University Student Health Centerwww.purdue.edu/PUSH . . . . . . . . . . . . . . . . . . .3Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4I.D. Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5UnitedHealthcare Network Pharmacy Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Preferred Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Accidental Death Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Continuation Privilege . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Monthly Continuation Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Coordination of Benefits Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Benefits for Pervasive Developmental Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Diabetes Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Benefits for Reconstructive Surgery and Prosthetic Device . . . . . . . . . . . . . . . . . . .15Benefits for Breast Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Benefits for Cancer Clinical Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Notice of Appeal Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Scholastic Emergency Services:Global Emergency Medical Assistance . . . . . . . . . . . .23Online Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24PUSH Contact Information and Hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

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Privacy Policy

We know that your privacy is important to you and we strive to protect the confidentiality ofyour nonpublic personal information. We do not disclose any nonpublic personalinformation about our customers or former customers to anyone, except as permitted orrequired by law. We believe we maintain appropriate physical, electronic and proceduralsafeguards to ensure the security of your nonpublic personal information. You may obtaina copy of our privacy practices by calling us toll-free at 1-888-224-4754 or by visiting usat www.uhcsr.com/purdue.

Eligibility

All graduate teaching or research assistants and graduate administrative staff employed 0.5FTE (20 hours) or more are eligible to enroll in this insurance Plan. Premium is payrolldeducted for students participating in the plan. Eligible dependents or same sex DomesticPartners of students enrolled in the plan may participate in the plan on a voluntary basis.Students must actively attend classes for at least the first 31 days after the date for whichcoverage is purchased. Home study, correspondence, and online courses do not fulfill theEligibility requirements that the student actively attend classes. The Company maintains itsright to investigate student status and attendance records to verify that the policy Eligibilityrequirements have been met. If the Company discovers the Eligibility requirements have notbeen met, its only obligation is to refund premium.Eligible graduate students who enroll may also insure their Dependents by completing theapplicable enrollment form within 31 days of becoming insured under the Plan. EligibleDependents are the spouse or same-sex domestic partners and dependent children under26 years of age. Dependent Eligibility expires concurrently with that of the Insured student.An insured graduate student may cover a new spouse or Dependent child by completingthe Graduate Staff Insurance Change Form and paying any pro-rata amount due within 31days of a marriage, birth, arrival in the US, or other acquisition of a Dependent.This plan is not an employer/employee plan or a group plan and is not meant tobe a fully comprehensive plan. It is a blanket student plan and contains limitedbenefits. Twelve months of previous continuous insurance is required to avoiddenied claims for pre-existing conditions. No lapse of coverage between plansmay occur. See the Pre-existing Condition Exclusion #21 on page 19 for additionalinformation.

Effective and Termination Dates

The Master Policy on file at the school becomes effective on 12:01 a.m. August 6, 2012.The Master Policy terminates on 11:59 p.m. August 5, 2013. The Individual Student’scoverage terminates on that date or at the end of the period through which premium is paid,whichever is earlier. Dependent coverage will not be effective prior to that of the Insuredstudent or extend beyond that of the Insured student.Refunds of premiums are allowed only upon entry into the armed forces.The Policy is a Non-Renewable One Year Term Policy.

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Annual Premium Rates

Eligible graduate students will pay an annual $432.00 rate. The University is subsidizingthe balance of the annual premium rate for eligible graduate students. All premiums will bepaid by monthly payroll deductions.

Student $ 1,826.00Spouse $ 2,520.00Dependent Child $ 909.00All Dependent Children $ 1,409.00

You must meet the Eligibility requirements each time you pay a premium to continueinsurance coverage. To avoid a lapse in coverage, your premium must be received within 30days after the coverage expiration date.

Extension of Benefits after Termination

The coverage provided under the Policy ceases on the Termination Date. However, if anInsured is Hospital Confined on the Termination Date from a covered Injury or Sickness forwhich benefits were paid before the Termination Date, Covered Medical Expenses for suchInjury or Sickness will continue to be paid as long as the condition continues but not toexceed 90 days after the Termination Date.The total payments made in respect of the Insured for such condition both before and afterthe Termination Date will never exceed the Maximum Benefit. After this "Extension ofBenefits" provision has been exhausted, all benefits cease to exist, and under nocircumstances will further payments be made.

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Purdue University Student Health Centerwww.purdue.edu/PUSH

The Purdue University Student Health Center (PUSH) provides outpatient care, excludingmaternity (labs are available) and pediatric services, for Purdue University students and theirspouses. Dependents are not eligible to receive Psychotherapy services at PUSH.The Graduate Staff Health Plan supplements the medical benefits provided by the StudentHealth Fee while at the Student Health Center, and also provides coverage in the localmedical community and when away from campus.There is a representative at PUSH (Room 338/340) to assist you with your student healthinsurance needs.Pediatric Care Pediatric Care is not provided at PUSH.Pre-natal VitaminsPre-natal vitamins are available at Purdue University Pharmacy. The pre-existing conditionexclusion does not apply to maternity. For additional information regarding Maternity Testing,please call the Company at 1-888-224-4754.Procedure for Seeking Medical TreatmentWhen on campus, if an Insured has an Injury or Sickness of a non-emergency nature (i.e., notlife-threatening) he/she should use the Purdue University Student Health Center (PUSH) asthe initial contact. Services rendered at PUSH are subject to a $15 Copay and the pre-existingcondition exclusion does not apply. PUSH services available to full-time students at no chargeare not subject to the $15 Copay. A $200 Deductible for Preferred Providers and a $400Deductible for Out-of-Network Providers will apply to all services outside PUSH with thefollowing exception: If PUSH is closed and you are seeking treatment for a medicalemergency (as defined by the Policy). For Medical Emergencies there is a $50 Copay forPreferred Providers or a $50 Deductible for Out-of-Network Providers (thisCopay/deductible is in lieu of the Policy Deductible).When seeking treatment outside of PUSH, students are encouraged by the University to utilizeservices provided by the UnitedHealthcare Choice Plus network. The UnitedHealthcare ChoicePlus network is available and may provide savings to insured students. To find out if there arehospitals or health care providers in your area who are part of the network, call the Company at1-888-224-4754 or visit the website at www.uhcsr.com/Purdue.Purdue Pharmacy and Prescription Drug InformationThe Purdue University pharmacy is the preferred pharmacy of the Fellowship Student Plan.Insured students and their insured dependents can have prescriptions filled at thepharmacy located in the RHPH building Room 118.A $10 Copay for generic and $20 Copay for brand name applies to each coveredprescription filled at the Purdue Pharmacy. When the Purdue Pharmacy is used, the plan willpay 100% above the $10 generic and $20 brand name Copay. When you do not use thePurdue Pharmacy, prescriptions must be filled at a UnitedHealthcare Network pharmacy.

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Benefits for Diabetes Insulin pumps/supplies and glucometers are not available at the Purdue UniversityPharmacy. Please contact PUSH Student Insurance Office for more information.Preventive CarePreventive Care Services are available at PUSH as well as Preferred Providers. Please seethe Schedule of Benefits for additional information.Benefits for Mental Illness Benefits will be paid the same as any other Sickness for the treatment of Mental Illness..Dependents are not eligible to receive Mental Illness Treatment services at PUSH.Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.

Pre-Admission Notification

UnitedHealthcare should be notified of all Hospital Confinements prior to admission.1. PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATIONS:

The patient, Physician or Hospital should telephone 1-877-295-0720 at least fiveworking days prior to the planned admission.

2. NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient,patient’s representative, Physician or Hospital should telephone 1-877-295-0720within two working days of the admission to provide the notification of anyadmission due to Medical Emergency.

UnitedHealthcare is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00 p.m.,C.S.T., Monday through Friday. Calls may be left on the Customer Service Department’svoice mail after hours by calling 1-877-295-0720.IMPORTANT: Failure to follow the notification procedures will not affect benefitsotherwise payable under the policy; however, pre-notification is not a guarantee thatbenefits will be paid.

I.D. Cards

Be sure to carry your ID card with you at all times. Please present your ID card each timeservices are rendered.

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Schedule of Medical Expense BenefitsInjury and Sickness

Maximum Benefit: $1,000,000 Paid As Specified Below (For Each Injury or Sickness)

Deductible Preferred Provider: $200 (Per Insured Person) (Per Policy Year)Deductible Out-of-Network: $400 (Per Insured Person) (Per Policy Year)

Deductible Out-of-Network: $400 (For all Insured in a Family, Per Policy Year)

Coinsurance Preferred Provider: 90% except as noted belowCoinsurance Out-of-Network: 70% except as noted below

Out-of-Pocket Maximum Preferred Providers: $1,500 (Per Insured Person, Per Policy Year)

Out-of-Pocket Maximum Preferred Providers: $3,500 (For all Insured in a Family, Per Policy Year)

Out-of-Pocket Maximum Out of Network: $3,000 (Per Insured Person, Per Policy Year)

Out-of-Pocket Maximum Out of Network: $7,000 (For all Insured in a Family, Per Policy Year)

The Preferred Providers for this plan is UnitedHealthcare Choice Plus.If care is received from a Preferred Provider any Covered Medical Expenses will be paidat the Preferred Provider level of benefits. If the Covered Medical Expense is incurred dueto a Medical Emergency, benefits will be paid at the Preferred Provider level of benefits.In all other situations, reduced or lower benefits will be provided when an Out-of-Networkprovider is used.Purdue Student Health Center Benefits: The Deductible will be waived when treatmentis rendered at the Purdue Student Health Center (PUSH) or for Medical Emergency whenthe PUSH is closed and Dependent children. University mandated vaccinations will bepayable when services are rendered at PUSH. Prenatal vitamins are covered at PUSHfollowing a Copay of $15.The Co-payments for PUSH services are $15 per visit. However, the Co-payments forPUSH services and Prescription Drugs do not apply toward the Deductible orCoinsurance provision.Out-of-Pocket Maximum: After the Out-of-Pocket Maximum has been satisfied, CoveredMedical Expenses will be paid at 100% up to the policy Maximum Benefit subject to anybenefit maximums that may apply. Separate Out-of-Pocket Maximums apply to PreferredProvider and Out-of-Network benefits. Copays and per service Deductibles and servicesthat are not Covered Medical Expenses do not count toward meeting the Out-of-PocketMaximum. Even when the Out-of-Pocket Maximum has been satisfied, the InsuredPerson will still be responsible for Copays and per service Deductibles.Benefits are subject to the policy Maximum Benefit unless otherwise specifically stated.Benefits will be paid up to the maximum benefit for each service as scheduled below. Allbenefit maximums are combined Preferred Provider and Out-of-Network unlessotherwise specifically stated. Covered Medical Expenses include:

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PA = Preferred Allowance U&C = Usual & Customary Charges

INPATIENTPreferredProviders

Out-of-NetworkProviders

Room and Board Expense, daily semi-private roomrate when confined as an Inpatient; and generalnursing care provided by the Hospital.

90% of PA 70% of U&C

Intensive Care Paid under Room and Board Expenses

Hospital Miscellaneous Expense, such as the costof the operating room, laboratory tests, x-rayexaminations, anesthesia, drugs (excluding take homedrugs) or medicines, therapeutic services, and supplies.In computing the number of days payable under thisbenefit, the date of admission will be counted, but notthe date of discharge.


Routine Newborn Care, while Hospital Confined; androutine nursery care provided immediately after birthfor an Inpatient stay of at least 48 hours following avaginal delivery or 96 hours following a cesareandelivery. If the mother agrees, the attending Physicianmay discharge the newborn earlier.

Paid as any other Sickness

Physiotherapy Paid under Hospital Miscellaneous

Surgeon’s Fees, If two or more procedures areperformed through the same incision or in immediatesuccession at the same operative session, themaximum amount paid will not exceed 50% of thesecond procedure and 50% of all subsequentprocedures.


Assistant Surgeon No Benefits

Anesthetist, professional services administered inconnection with Inpatient surgery.


Registered Nurse’s Services No Benefits

Physician’s Visits, non-surgical services whenconfined as an Inpatient. Benefits are limited to onevisit per day and do not apply when related to surgery.(30 days maximum)


Pre-Admission Testing, payable within 5 workingdays prior to admission.

Paid under Hospital Miscellaneous

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OUTPATIENTPreferredProviders


Surgeon’s Fees, if two or more procedures areperformed through the same incision or in immediatesuccession at the same operative session, the maximumamount paid will not exceed 50% of the secondprocedure and 50% of all subsequent procedures.


Day Surgery Miscellaneous, related to scheduledsurgery performed in a Hospital, including the cost ofthe operating room; laboratory tests and x-rayexaminations, including professional fees; anesthesia;drugs or medicines; and supplies. Usual and CustomaryCharges for Day Surgery Miscellaneous are based onthe Outpatient Surgical Facility Charge Index.


Assistant Surgeon No Benefits

Anesthetist, professional services administered inconnection with outpatient surgery.


Physician’s Visits, benefits are limited to one visit perday. Benefits for Physician’s Visits do not apply whenrelated to surgery or Physiotherapy.


Physiotherapy, benefits are limited to one visit per day.Physiotherapy includes but is not limited to thefollowing: 1) physical therapy; 2) occupational therapy;3) cardiac rehabilitation therapy; 4) manipulativetreatment; and 5) speech therapy. Speech therapy willbe paid only for the treatment of speech, language,voice, communication and auditory processing whenthe disorder results from Injury, trauma, stroke, surgery,cancer or vocal nodules.Review of Medical Necessity will be performed after 12visits per Injury or Sickness.


Medical Emergency Expenses, facility charge foruse of the emergency room and supplies. Treatmentmust be rendered within 72 hours from time of Injury orfirst onset of Sickness. (The Copay/per visit Deductibleis in lieu of the Policy Deductible.)

90% of PA $50 Copay per visit

90% of U&C$50 Deductible

per visit

Diagnostic X-ray Services 90% of PA 70% of U&C

Radiation Therapy 90% of PA 70% of U&C

Chemotherapy 90% of PA 70% of U&C

Laboratory Services 90% of PA 70% of U&C

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OUTPATIENTPreferredProviders


Tests & Procedures, diagnostic services and medicalprocedures performed by a Physician, other thanPhysician’s Visits, Physiotherapy, X-Rays and LabProcedures. The following therapies will be paid underthis benefit: inhalation therapy, infusion therapy,pulmonary therapy and respiratory therapy.A Quantifieron Gold TB test will be covered whenadministered at PUSH.


Injections, when administered in the Physician's officeand charged on the Physician's statement.


Prescription Drugs, includes Acne and Allergy medications, and prenatalvitamins.Prescriptions filled at Purdue Pharmacy, the plan will pay 100% above thefollowing Copays:w $10 Copay for generic;w $20 Copay for brand name;If you do not use the Purdue Pharmacy, prescriptions must be filled at aUnitedHealthcare Network Pharmacy (up to a 31 day supply per prescription).Copay greater of:w $20 Copay for Tier 1 prescriptions;w $40 Copay for Tier 2 prescriptions; orw 30% Coinsurance up to a $1,000 Out-of-Pocket maximum.After the $1,000 maximum:Copay greater of:w $20 Copay for Tier 1 prescriptions;w $40 Copay for Tier 2 prescriptions; orw 10% CoinsuranceMail order Prescription Drugs through UnitedHealthcare Network Pharmacyat 2 times the retail Copay up to a 90 day supply.

No Benefits

OTHERPreferredProviders


Ambulance Services 90% of U&C 90% of U&C

Durable Medical Equipment No Benefits

Consultant Physician Fees, when requested andapproved by attending Physician.


Dental Treatment, made necessary by Injury to Sound,Natural Teeth only.(Benefits are not subject to the $1,000,000 MaximumBenefit.)

90% of U&C 90% of U&C

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Mental Illness Treatment, services received on anInpatient and outpatient basis. Benefits are limited toone visit per day.


Substance Use Disorder Treatment, servicesreceived on an Inpatient and outpatient basis. Benefitsare limited to one visit per day.


Maternity, benefits will be paid for an Inpatient stay ofat least 48 hours following a vaginal delivery or 96hours following a cesarean delivery. If the motheragrees, the attending Physician may discharge themother earlier.Pre-Existing condition exclusion does not apply to theMaternity benefit.


Complications of Pregnancy Paid as any other Sickness

Elective Abortion No Benefits

Preventive Care Services, medical services that havebeen demonstrated by clinical evidence to be safe andeffective in either the early detection of disease or inthe prevention of disease, have been proven to have abeneficial effect on health outcomes and are limited tothe following as required under applicable law: 1)Evidence-based items or services that have in effect arating of “A” or “B” in the current recommendations ofthe United States Preventive Services Task Force; 2)immunizations that have in effect a recommendationfrom the Advisory Committee on ImmunizationPractices of the Centers for Disease Control andPrevention; 3) with respect to infants, children, andadolescents, evidence-informed preventive care andscreenings provided for in the comprehensiveguidelines supported by the Health Resources andServices Administration; and 4) with respect to women,such additional preventive care and screeningsprovided for in comprehensive guidelines supported bythe Health Resources and Services Administration.No Deductible, Copays or Coinsurance will be appliedwhen the services are received from a PreferredProvider.

100% of PA No Benefits

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Reconstructive Breast Surgery FollowingMastectomy, in connection with a coveredMastectomy.See Benefits for Reconstructive Surgery and Prosthetic Device.


Diabetes Services, in connection with the treatmentof diabetes.See Diabetes Benefit.


Smoking Cessation Paid as any other Sickness

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UnitedHealthcare Network Pharmacy Benefits

Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL)when dispensed by a UnitedHealthcare Network Pharmacy. Benefits are subject to supplylimits and Copayments and/or Coinsurance that vary depending on which tier of the PDLthe outpatient drug is listed. There are certain Prescription Drugs that require your Physicianto notify us to verify their use is covered within your benefit.You are responsible for payingthe applicable Copayments and/or Coinsurance. Your Copayment/Coinsurance isdetermined by the tier to which the Prescription Drug Product is assigned on the PDL. Tierstatus may change periodically and without prior notice to you. Please accesswww.uhcsr.com or call 877-417-7345 for the most up-to-date tier status. Copays per prescription order or refill: The greater of $20 for Tier 1; $40 for Tier 2; or 30% Coinsurance up to a 31-day supply.Out-of pocket maximum: After the Insured has paid $1,000 in out-of-pocket expenses for Prescription Drugs, thenthe greater of $20 for Tier 1; $40 for Tier 2; or 10% Coinsurance per prescription order orrefill up to a 31-day supply.Mail order Prescription Drugs are available at 2 times the retail Copay up to a 90 day supply.Please present your ID card to the network pharmacy when the prescription is filled. If you donot use a network pharmacy, you will be responsible for paying the full cost of the prescription.If you do not present the card, you will need to pay for the prescription and then submit areimbursement form for prescriptions filled at a network pharmacy along with the paidreceipt in order to be reimbursed. To obtain reimbursement forms please visitwww.uhcsr.com and log in to your on-line account, or call 877-417-7345.Additional ExclusionsIn addition to the policy Exclusions and Limitations, the following Exclusions apply toNetwork Pharmacy Benefits:

1. Coverage for Prescription Drug Products for the amount dispensed (days' supply orquantity limit) which exceeds the supply limit.

2. Experimental or Investigational Services or Unproven Services and medications;medications used for experimental indications and/or dosage regimens determined bythe Company to be experimental, investigational or unproven.

3. Compounded drugs that do not contain at least one ingredient that has been approvedby the U.S. Food and Drug Administration and requires a Prescription Order or Refill.Compounded drugs that are available as a similar commercially available PrescriptionDrug Product. Compounded drugs that contain at least one ingredient that requiresa Prescription Order or Refill are assigned to Tier-2.

4. Drugs available over-the-counter that do not require a Prescription Order or Refill by federalor state law before being dispensed, unless the Company has designated the over-the-counter medication as eligible for coverage as if it were a Prescription Drug Product and it isobtained with a Prescription Order or Refill from a Physician. Prescription Drug Products thatare available in over-the-counter form or comprised of components that are available in over-the-counter form or equivalent. Certain Prescription Drug Products that the Company hasdetermined are Therapeutically Equivalent to an over-the-counter drug. Such determinationsmay be made up to six times during a calendar year, and the Company may decide at anytime to reinstate Benefits for a Prescription Drug Product that was previously excluded underthis provision.

5. Any product for which the primary use is a source of nutrition, nutritional supplements, ordietary management of disease, even when used for the treatment of Sickness or Injury.

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DefinitionsPrescription Drug or Prescription Drug Product means a medication, product or devicethat has been approved by the U.S. Food and Drug Administration and that can, underfederal or state law, be dispensed only pursuant to a Prescription Order or Refill. APrescription Drug Product includes a medication that, due to its characteristics, isappropriate for self-administration or administration by a non-skilled caregiver. For thepurpose of the benefits under the policy, this definition includes insulin.Prescription Drug List means a list that categorizes into tiers medications, products ordevices that have been approved by the U.S. Food and Drug Administration. This list issubject to the Company’s periodic review and modification (generally quarterly, but no morethan six times per calendar year). The Insured may determine to which tier a particularPrescription Drug Product has been assigned through the Internet at www.uhcsr.com or callCustomer Service at 1-877-417-7345.

Preferred Provider Information

“Preferred Providers” are the Physicians, Hospitals and other health care providers whohave contracted to provide specific medical care at negotiated prices. Preferred Providersin your local school area and nationally are: Hospitals and Physicians participating in theUnitedHealthcare Choice Plus Network.The availability of specific providers is subject to change without notice. Insured’s shouldalways confirm that a Preferred Provider is participating at the time services are required bycalling the Company at 1-888-224-4754, and/or by asking the provider when making anappointment for services."Preferred Allowance" means the amount a Preferred Provider will accept as payment infull for Covered Medical Expenses."Out of Network" providers have not agreed to any prearranged fee schedules. Insured'smay incur significant expenses with these providers. Charges in excess of the insurancepayment are the Insured's responsibility.Regardless of the provider, each Insured is responsible for the payment of their Deductible.The Deductible must be satisfied before benefits are paid. The Company will pay accordingto the benefit limits in the Schedule of Benefits.PREFERRED PROVIDERS - Eligible Inpatient expenses at a Preferred Provider will bepaid at the Coinsurance percentages specified in the Schedule of Benefits, up to any limitsspecified in the Schedule of Benefits. Call 1-888-224-4754 for information aboutPreferred Hospitals.OUT-OF-NETWORK PROVIDERS - If Inpatient care is not provided at a PreferredProvider, eligible Inpatient expenses will be paid according to the benefit limits in theSchedule of Benefits.Outpatient Hospital ExpensesPreferred Providers may discount bills for outpatient Hospital expenses. Benefits are paidaccording to the Schedule of Benefits. Insureds are responsible for any amounts thatexceed the benefits shown in the Schedule, up to the Preferred Allowance. Professional & Other ExpensesBenefits for Covered Medical Expenses provided by UnitedHealthcare Choice Plusproviders will be paid at the Coinsurance percentages specified in the Schedule of Benefits,or up to any limits specified in the Schedule of Benefits. All other providers will be paidaccording to the benefit limits in the Schedule of Benefits.Insureds will be responsible for all expenses in excess of the policy limits contained in theSchedule of Benefits.

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Maternity Testing

This policy does not cover all routine, preventive, or screening examinations or testing. Thefollowing maternity tests and screening exams will be considered for payment according tothe policy benefits if all other policy provisions have been met.Initial screening at first visit:

• Pregnancy test: urine human chorionic gonatropin (HCG)• Asymptomatic bacteriuria: urine culture • Blood type and Rh antibody • Rubella • Pregnancy-associated plasma protein-A (PAPPA) (first trimester only)• Free beta human chorionic gonadotrophin (hCG) (first trimester only)• Hepatitis B: HBsAg • Pap smear • Gonorrhea: Gc culture • Chlamydia: chlamydia culture • Syphilis: RPR • HIV: HIV-ab• Coombs test

Each visit: Urine analysisOnce every trimester: Hematocrit and Hemoglobin Once during first trimester: Ultrasound Once during second trimester:

• Ultrasound (anatomy scan) • Triple Alpha-fetoprotein (AFP), Estriol, hCG or Quad screen test Alpha-fetoprotein

(AFP), Estriol, hCG, inhibin-a Once during second trimester if age 35 or over: Amniocentesis or Chorionic villussampling (CVS)Once during second or third trimester: 50g Glucola (blood glucose 1 hourpostprandial)Once during third trimester: Group B Strep Culture Pre-natal vitamins are covered at PUSH only. For additional information regardingMaternity Testing, please call the Company at 1-800-767-0700.

Accidental Death Benefit

If an accidental Injury should independently of all other causes and within 90 days from thedate of Injury solely result in the loss of the Insured’s life, the Insured’s beneficiary mayrequest the Company to pay $25,000 in addtion to payment under any Medical ExpenseBenefit provisions.

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Continuation Privilege

All Insured Persons who have been continuously insured under the school's regular studentPolicy for at least 6 consecutive months and who no longer meet the Eligibility requirementsunder that Policy are eligible to continue their coverage for a period of not more than 90 daysunder the school's policy in effect at the time of such continuation. If an Insured Person is stilleligible for continuation at the beginning of the next Policy Year, the insured must purchasecoverage under the new policy as chosen by the school. Coverage under the new policy issubject to the rates and benefits selected by the school for that policy year. Application mustbe made and premium must be paid directly to UnitedHealthcare StudentResources and bereceived within 14 days after the expiration date of your student coverage. For furtherinformation on the Continuation privilege, please contact UnitedHealthcareStudentResources at 1-888-224-4754 or PUSH Student Insurance office.

Monthly Continuation Rates

Student Only $ 143.00Spouse $ 660.00Each Child $ 225.00

Coordination of Benefits Provision

Benefits will be coordinated with any other eligible medical, surgical or hospital plan orcoverage, so that combined payments under all programs will not exceed 100% ofallowable expenses incurred for covered services and supplies.

Mandated Benefits

Benefits for Pervasive Developmental Disorder

Benefits will be provided in accordance with a Physician’s treatment plan for pervasivedevelopmental disorder. Services will be provided without interruption, as long as thoseservices are consistent with the treatment plan and with Medical Necessity decisions. As usedin this benefit, “Pervasive Developmental Disorder” means a neurological condition includingAsperger’s Syndrome and Autism, as defined in the most recent edition of the Diagnostic andStatistical Manual of Mental Disorders of the American Psychiatric Association.Benefits shall be subject to all Deductible, Copayment, Coinsurance, and lifetimemaximums, but any other exclusions and limitations within the policy that are inconsistentwith the treatment do not apply.

Diabetes Benefit

Benefits will be paid the same as any other Sickness for the Medically Necessary treatmentof Diabetes including the equipment and supplies for the treatment of Insulin-using, Non-insulin using diabetics, or elevated blood glucose levels induced by pregnancy or othermedical conditions, when recommended or prescribed by a Physician.Benefits will also be provided for self-management training for one or more visits afterreceiving a diagnosis of Diabetes by a Physician, or a diagnosis that represents a significantchange in the Insured's symptoms or condition and makes changes in the Insured's self-management Medically Necessary. Benefits will be provided for one or more visits forreeducation or refresher training.Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.

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Benefits for Reconstructive Surgery and Prosthetic Device

Benefits will be paid the same as any other Sickness for prosthetic devices andreconstructive surgery incident to a mastectomy. Surgery benefits shall include all stagesof reconstruction of the breast on which the mastectomy has been performed and surgicalreconstruction of the other breast to produce symmetry if recommended by a Physician. Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the Policy.

Benefits for Breast Cancer Screening

Benefits will be paid the same as any other Sickness for breast cancer screeningmammography performed on dedicated equipment for diagnostic purposes on referral by aPhysician according to the following guidelines:

1. One baseline mammogram for an Insured at least thirty-five but less than fortyyears of age, or more often if recommended by a Physician; or

2. One mammogram every year for an Insured who is less than forty years of age, andconsidered a woman at risk.A woman at risk is defined as a woman who meets at least one of the followingdescriptions:- A woman who has a personal history of breast cancer.- A woman who has a personal history of breast disease that was proven benign

by biopsy.- A woman whose mother, sister, or daughter has had breast cancer.- A woman who is at least thirty (30) years of age and has not given birth.

3. One mammogram every year for an Insured at least forty years of age.4. Any additional mammography views that are required for proper evaluation.5. Ultrasound services, if determined Medically Necessary by the Physician treating

the Insured.This benefit is in addition to any other benefits specifically provided for x-rays, laboratorytesting, or Sickness examinations.Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the Policy.

Benefits for Cancer Clinical Trials

Benefits will be paid the same as any other Sickness for Routine Care Costs that areincurred in the course of a Clinical Trial if the policy would provide benefits for the sameRoutine Care Costs not incurred in a Clinical Trial. “Routine Care Cost” means the cost of Medically Necessary services related to the CareMethod that is under evaluation in a Clinical Trial. It does not include:

1. Health care service, item, or investigational drug that is the subject of the Clinical Trial.2. Any treatment modality that is not part of the Usual and Customary standard of care

required to administer or support the health care service, item, or investigationaldrug that is the subject of the Clinical Trial.

3. Any health care service, item, or drug provided solely to satisfy data collection andanalysis needs that are not used in the direct clinical management of the patient.

4. An investigational drug or device that has not been approved for market by thefederal Food and Drug Administration.

5. Transportation, lodging, food, or other expenses for the Insured or a family memberor companion of the Insured that are associated with travel to or from a facilitywhere a Clinical Trial is conducted.

6. A service, item, or drug that is provided by a Clinical Trial sponsor free of charge forany new patient.

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7. A service, item, or drug that is eligible for reimbursement from a source other thanan Insured’s individual contract or group contract, including the sponsor of theClinical Trial.

"Clinical Trial" means a Phase I, II, III, or IV research study:1. That is conducted:

(A) using a particular Care Method to prevent, diagnose, or treat a cancer forwhich: (i) there is no clearly superior, noninvestigational alternative CareMethod; and (ii) available clinical or preclinical data provides a reasonablebasis from which to believe that the Care Method used in the research studyis at least as effective as any noninvestigational alternative Care Method;

(B) in a facility where personnel providing the Care Method to be followed in theresearch study have: (i) received training in providing the Care Method; (ii)expertise in providing the type of care required for the research study; and (iii)experience providing the type of care required for the research study to asufficient volume of patients to maintain expertise; and

(C) to scientifically determine the best Care Method to prevent, diagnose, or treatthe cancer; and

2. That is approved or funded by one of the following:(A) A National Institutes of Health institute;(B) A cooperative group of research facilities that has an established peer review

program that is approved by a National Institutes of Health institute or center;(C) The federal Food and Drug Administration;(D) The United States Department of Veterans Affairs;(E) The United States Department of Defense;(F) The institutional review board of an institution located in Indiana that has a

multiple project assurance contract approved by the National Institutes ofHealth Office for Protection from Research Risks as provided in 45 CFR46.103; or

(G) A research entity that meets eligibility criteria for a support grant from aNational Institutes of Health center.

“Care Method” means the use of a particular drug or device in a particular manner.Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.

Definitions

COPAY/COPAYMENT means a specified dollar amount that the Insured is required to payfor certain Covered Medical Expenses.COVERED MEDICAL EXPENSES means reasonable charges which are: 1) not inexcess of Usual and Customary Charges; 2) not in excess of the Preferred Allowance whenthe policy includes Preferred Provider benefits and the charges are received from aPreferred Provider; 3) not in excess of the maximum benefit amount payable per service asspecified in the Schedule of Benefits; 4) made for services and supplies not excluded underthe policy; 5) made for services and supplies which are a Medical Necessity; 6) made forservices included in the Schedule of Benefits; and 7) in excess of the amount stated as aDeductible, if any.Covered Medical Expenses will be deemed "incurred" only: 1) when the covered servicesare provided; and 2) when a charge is made to the Insured Person for such services.

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DEDUCTIBLE means if an amount is stated in the Schedule of Benefits or anyendorsement to this policy as a deductible, it shall mean an amount to be subtracted fromthe amount or amounts otherwise payable as Covered Medical Expenses before paymentof any benefit is made. The deductible will apply as specified in the Schedule of Benefits.DOMESTIC PARTNER means a person who is neither married nor related by blood ormarriage to the Named Insured but who is: 1) the Named Insured’s sole spousal equivalent;2) lives together with the Named Insured in the same residence and intends to do soindefinitely; and 3) is responsible with the Named Insured for each other’s welfare; and 4)is the same sex as the Named Insured. A domestic partner relationship may bedemonstrated by any three of the following types of documentation: 1) a joint mortgage orlease; 2) designation of the domestic partner as beneficiary for life insurance; 3)designation of the domestic partner as primary beneficiary in the Named Insured’s will; 4)domestic partnership agreement; 5) powers of attorney for property and/or health care; and6) joint ownership of either a motor vehicle, checking account or credit account.ELECTIVE SURGERY OR ELECTIVE TREATMENT means those health care services orsupplies that do not meet the health care need for a Sickness or Injury. Elective surgery orelective treatment includes any service, treatment or supplies that: 1) are deemed by theCompany to be research or experimental; or 2) are not recognized and generally acceptedmedical practices in the United States.HOSPITAL means a licensed or properly accredited general hospital which: 1) is open atall times; 2) is operated primarily and continuously for the treatment of and surgery for sickand injured persons as inpatients; 3) is under the supervision of a staff of one or morelegally qualified Physicians available at all times; 4) continuously provides on the premises24 hour nursing service by Registered Nurses; 5) provides organized facilities for diagnosisand major surgery on the premises; and 6) is not primarily a clinic, nursing, rest orconvalescent home.INJURY means bodily injury which is all of the following:

1) directly and independently caused by specific accidental contact with another bodyor object.

2) unrelated to any pathological, functional, or structural disorder. 3) a source of loss.4) treated by a Physician within 30 days after the date of accident.5) sustained while the Insured Person is covered under this policy.

All injuries sustained in one accident, including all related conditions and recurrentsymptoms of these injuries will be considered one injury. Injury does not include loss whichresults wholly or in part, directly or indirectly, from disease or other bodily infirmity. CoveredMedical Expenses incurred as a result of an injury that occurred prior to this policy’sEffective Date will be considered a Sickness under this policy.INPATIENT means an uninterrupted confinement that follows formal admission to aHospital by reason of an Injury or Sickness for which benefits are payable under this policy.MEDICAL EMERGENCY means the occurrence of a sudden, serious and unexpectedSickness or Injury. In the absence of immediate medical attention, a reasonable personcould believe this condition would result in any of the following:

1) Death.2) Placement of the Insured's health in jeopardy.3) Serious impairment of bodily functions.4) Serious dysfunction of any body organ or part.5) In the case of a pregnant woman, serious jeopardy to the health of the fetus.

Expenses incurred for "Medical Emergency" will be paid only for Sickness or Injury which fulfillsthe above conditions. These expenses will not be paid for minor Injuries or minor Sicknesses.

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MEDICAL NECESSITY means those services or supplies provided or prescribed by aHospital or Physician which are all of the following:

1) Essential for the symptoms and diagnosis or treatment of the Sickness or Injury.2) Provided for the diagnosis, or the direct care and treatment of the Sickness or Injury.3) In accordance with the standards of good medical practice.4) Not primarily for the convenience of the Insured, or the Insured's Physician.5) The most appropriate supply or level of service which can safely be provided to the Insured.

The Medical Necessity of being confined as an Inpatient means that both: 1) The Insured requires acute care as a bed patient.2) The Insured cannot receive safe and adequate care as an outpatient.

This policy only provides payment for services, procedures and supplies which are a MedicalNecessity. No benefits will be paid for expenses which are determined not to be a MedicalNecessity, including any or all days of Inpatient confinement.MENTAL ILLNESS means a Sickness that is a mental, emotional or behavioral disorderlisted in the mental health or psychiatric diagnostic categories in the current Diagnostic andStatistical Manual of the American Psychiatric Association. The fact that a disorder is listedin the Diagnostic and Statistical Manual of the American Psychiatric Association does notmean that treatment of the disorder is a Covered Medical Expense. OUT-OF-POCKET MAXIMUM means the amount of Covered Medical Expenses thatmust be paid by the Insured Person before Covered Medial Expenses will be paid at 100%for the remainder of the Policy Year according to the policy Schedule of Benefits. Thefollowing expenses do not apply toward meeting the Out-of-Pocket Maximum, unlessotherwise specified in the policy Schedule of Benefits:

1) Deductibles.2) Copays.3) Expenses that are not Covered Medical Expenses.

PRE-EXISTING CONDITION means: 1) the existence of symptoms which would causean ordinarily prudent person to seek diagnosis, care or treatment within the 6 monthsimmediately prior to the Insured's Effective Date under the policy; or, 2) any condition whichoriginates, is diagnosed, treated or recommended for treatment within the 6 monthsimmediately prior to the Insured's Effective Date under the policy.SICKNESS means sickness or disease of the Insured Person which causes loss, andoriginates while the Insured Person is covered under this policy. All related conditions andrecurrent symptoms of the same or a similar condition will be considered one sickness.Covered Medical Expenses incurred as a result of an Injury that occurred prior to thispolicy's Effective Date will be considered a sickness under this policy.USUAL AND CUSTOMARY CHARGES means the lesser of the actual charge or areasonable charge which is: 1) usual and customary when compared with the chargesmade for similar services and supplies; and 2) made to persons having similar medicalconditions in the locality of the Policyholder. The Company uses data from FAIR Health, Inc.to determine Usual and Customary Charges. No payment will be made under this policy forany expenses incurred which in the judgment of the Company are in excess of Usual andCustomary Charges.

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Exclusions and Limitations

No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from;or b) treatment, services or supplies for, at, or related to any of the following:

1. Acupuncture; 2. Assistant Surgeon Fees;3. Learning disabilities;4. Biofeedback;5. Durable Medical Equipment;6. Circumcision;7. Congenital conditions, except as specifically provided for Newborn or adopted Infants;8. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which

benefits are otherwise payable under this policy or for newborn or adopted children; 9. Dental treatment, except for accidental Injury to Sound, Natural Teeth;

10. Elective Surgery or Elective Treatment; 11. Elective Abortion;12. Eye examinations, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or

contact lenses, except when due to a covered Injury or disease process;13. Routine foot care including the care, cutting and removal of corns, calluses, and

bunions (except capsular or bone surgery); 14. Hearing examinations; hearing aids; or other treatment for hearing defects and

problems, except as a result of an infection or trauma. "Hearing defects" means anyphysical defect of the ear which does or can impair normal hearing, apart from thedisease process;

15. Hirsutism; alopecia;16. Immunizations, except as specifically provided in the policy; preventive medicines or

vaccines, except where required for treatment of a covered Injury or as specificallyprovided in the policy;

17. Injury or Sickness for which benefits are paid or payable under any Workers'Compensation or Occupational Disease Law or Act, or similar legislation;

18. Injury sustained while (a) participating in any interscholastic, intercollegiate,professional sport, contest or competition; (b) traveling to or from such sport, contestor competition as a participant; or (c) while participating in any practice or conditioningprogram for such sport, contest or competition;

19. Organ transplants, including organ donation;20. Participation in a riot or civil disorder; commission of or attempt to commit a felony; or

fighting;21. Pre-existing Conditions, except for individuals who have been continuously insured

under the school's student insurance policy for at least 12 consecutive months; ThePre-existing Condition exclusionary period will be reduced by the total number ofmonths that the Insured provides documentation of continuous coverage under a priorhealth insurance policy which provided benefits similar to this policy. This exclusiondoes not apply to students continuously covered under the policy issued by theCompany for the previous policy year. This exclusion will not be applied to an InsuredPerson who is under age 19;

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22. Prescription Drugs, services or supplies as follows:a) Therapeutic devices or appliances, including: hypodermic needles, syringes,

support garments and other non-medical substances, regardless of intended use,except as specifically provided in the policy;

b) Immunization agents, except as specifically provided in the policy, biological sera,blood or blood products administered on an outpatient basis;

c) Drugs labeled, “Caution - limited by federal law to investigational use” orexperimental drugs;

d) Products used for cosmetic purposes;e) Drugs used to treat or cure baldness; anabolic steroids used for body building;f) Anorectics - drugs used for the purpose of weight control;g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid,

Profasi, Metrodin, Serophene, or Viagra;h) Growth hormones; ori) Refills in excess of the number specified or dispensed after one (1) year of date of

the prescription;23. Reproductive/Infertility services including but not limited to: family planning; fertility

tests; infertility (male or female), including any services or supplies rendered for thepurpose or with the intent of inducing conception; premarital examinations; impotence,organic or otherwise; female sterilization procedures, except as specifically providedin the policy; vasectomy; sexual reassignment surgery; reversal of sterilizationprocedures;

24. Preventive care services; routine physical examinations and routine testing; preventivetesting or treatment; screening exams or testing in the absence of Injury or Sickness;except as specifically provided in the policy;

25. Services provided normally without charge by the Health Service of the Policyholder;or services covered or provided by the student health fee;

26. Skeletal irregularities of one or both jaws, including orthognathia and mandibularretrognathia; temporomandibular joint dysfunction; nasal and sinus surgery, except fortreatment of a covered Injury; This exclusion does not apply to newborns;

27. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungeejumping, or flight in any kind of aircraft, except while riding as a passenger on aregularly scheduled flight of a commercial airline or while taking flight instructions forUniversity credit;

28. Sleep disorders;29. Supplies, except as specifically provided in the policy;30. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic

devices, or gynecomastia; except as specifically provided in the policy;31. Treatment in a Government hospital, unless there is a legal obligation for the Insured

Person to pay for such treatment; 32. War or any act of war, declared or undeclared; or while in the armed forces of any

country (a pro-rata premium will be refunded upon request for such period notcovered); and

33. Weight management, weight reduction, nutrition programs, treatment for obesity,surgery for removal of excess skin or fat.

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Notice of Appeal Rights

Right to Internal AppealStandard Internal AppealThe Insured Person has the right to request an Internal Appeal if the Insured Persondisagrees with the Company’s denial, in whole or in part, of a claim or request for benefits.The Insured Person, or the Insured Person’s Authorized Representative, must submit awritten request for an Internal Appeal within 180 days of receiving a notice of theCompany’s Adverse Determination.The written Internal Appeal request should include:

1. A statement specifically requesting an Internal Appeal of the decision;2. The Insured Person’s Name and ID number (from the ID card);3. The date(s) of service;4. The Provider’s name;5. The reason the claim should be reconsidered; and6. Any written comments, documents, records, or other material relevant to the claim.

Please contact the Customer Service Department at 800-767-0700 with any questionsregarding the Internal Appeal process. The written request for an Internal Appeal should besent to: UnitedHealthcare StudentResources, PO Box 809025, Dallas, TX 75380-9025.Expedited Internal AppealFor Urgent Care Requests, an Insured Person may submit a request, either orally or inwriting, for an Expedited Internal Appeal. An Urgent Care Request means a request for services or treatment where the time periodfor completing a standard Internal Appeal:

1. Could seriously jeopardize the life or health of the Insured Person or jeopardize theInsured Person’s ability to regain maximum function; or2. Would, in the opinion of a Physician with knowledge of the Insured Person’s medicalcondition, subject the Insured Person to severe pain that cannot be adequatelymanaged without the requested health care service or treatment.

To request an Expedited Internal Appeal, please contact Claims Appeals at 888-315-0447.The written request for an Expedited Internal Appeal should be sent to: Claims Appeals,UnitedHealthcare StudentResources, PO Box 809025, Dallas, TX 75380-9025.Right to External Independent ReviewAfter exhausting the Company’s Internal Appeal process, the Insured Person, or the InsuredPerson’s Authorized Representative, has the right to request an External IndependentReview when the service or treatment in question:

1. Is a Covered Medical Expense under the Policy; and2. Is not covered because it does not meet the Company’s requirements for Medical

Necessity, appropriateness, health care setting, level or care, or effectiveness. Standard External ReviewA Standard External Review request must be submitted in writing within 4 months ofreceiving a notice of the Company’s Adverse Determination or Final Adverse Determination.

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Expedited External ReviewAn Expedited External Review request may be submitted either orally or in writing when:

1. The Insured Person or the Insured Person’s Authorized Representative has receivedan Adverse Determination, anda. The Insured Person, or the Insured Person’s Authorized Representative, has

submitted a request for an Expedited Internal Appeal; and b. Adverse Determination involves a medical condition for which the time frame for

completing an Expedited Internal Review would seriously jeopardize the life orhealth of the Insured Person or jeopardize the Insured Person’s ability to regainmaximum function;

or2. The Insured Person or the Insured Person’s Authorized Representative has received

a Final Adverse Determination, anda. The Insured Person has a medical condition for which the time frame for

completing a Standard External Review would seriously jeopardize the life orhealth of the Insured Person or jeopardize the Insured Person’s ability to regainmaximum function; or

b. The Final Adverse Determination involves an admission, availability of care,continued stay, or health care service for which the Insured Person receivedemergency services, but has not been discharged from a facility.

Where to Send External Review RequestsAll types of External Review requests shall be submitted to Claims Appeals at thefollowing address:

Claims AppealsUnitedHealthcare StudentResourcesPO Box 809025Dallas, TX 75380-9025888-315-0447

Collegiate Assistance Program

Insured Students have access to nurse advice, health information, and counseling support 24hours a day, 7 days a week by dialing the access number indicated on your permanent ID card.Collegiate Assistance Program is staffed by Registered Nurses and Licensed Clinicians who canhelp students determine if they need to seek medical care, need legal/financial advice or mayneed to talk to someone about everyday issues that can be overwhelming.

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Scholastic Emergency Services:Global Emergency Medical Assistance

If you are a student insured with this insurance plan, you and your insured spouse or samesex Domestic Partner and minor child(ren) are eligible for Scholastic Emergency Services(SES). The requirements to receive these services are as follows:International Students, insured spouse or same sex Domestic Partner and insured minorchild(ren): You are eligible to receive SES worldwide, except in your home country.Domestic Students, insured spouse or same sex Domestic Partner and insured minorchild(ren): You are eligible for SES when 100 miles or more away from your campusaddress and 100 miles or more away from your permanent home address or whileparticipating in a Study Abroad program. SES includes Emergency Medical Evacuation and Return of Mortal Remains that meet theUS State Department requirements. The Emergency Medical Evacuation services are notmeant to be used in lieu of or replace local emergency services such as an ambulancerequested through emergency 911 telephone assistance. All SES services must bearranged and provided by SES, Inc.; any services not arranged by SES, Inc. will not beconsidered for payment. Key Services include:

* Medical Consultation, Evaluation and Referrals * Prescription Assistance* Foreign Hospital Admission Guarantee * Critical Care Monitoring* Emergency Medical Evacuation * Return of Mortal Remains* Medically Supervised Repatriation * Transportation to Join Patient* Emergency Counseling Services * Interpreter and Legal Referrals* Lost Luggage or Document Assistance* Care for Minor Children Left Unattended Due to a Medical Incident

Please visit your school's insurance coverage page at www.uhcsr.com for the SES GlobalEmergency Assistance Services brochure which includes service descriptions and programexclusions and limitations.To access services please call:(877) 488-9833 Toll-free within the United States(609) 452-8570 Collect outside the United StatesServices are also accessible via e-mail at [email protected] calling the SES Operations Center, please be prepared to provide:

1. Caller's name, telephone and (if possible) fax number, and relationship to the patient;2. Patient's name, age, sex, and Reference Number;3. Description of the patient's condition;4. Name, location, and telephone number of hospital, if applicable;5. Name and telephone number of the attending physician; and6. Information of where the physician can be immediately reached.

SES is not travel or medical insurance but a service provider for emergency medicalassistance services. All medical costs incurred should be submitted to your health plan andare subject to the policy limits of your health coverage. All assistance services must bearranged and provided by SES, Inc. Claims for reimbursement of services not provided bySES will not be accepted. Please refer to your SES brochure or Program Guide atwww.uhcsr.com for additional information, including limitations and exclusions pertaining tothe SES program.

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Online Access to Account Information

UnitedHealthcare StudentResources Insureds have online access to claims status, EOBs,correspondence and coverage information via My Account at www.uhcsr.com/purdue.Insureds can also print a temporary ID card, request a replacement ID card and locatenetwork providers from My Account. If you don’t already have an online account, simply select the “Create an Account” link fromthe home page at www.uhcsr.com/purdue. Follow the simple, onscreen directions toestablish an online account in minutes. Note that you will need your 7-digit insurance IDnumber to create an online account. If you already have an online account, just log in fromwww.uhcsr.com/purdue to access your account information.

Claim Procedure

In the event of Injury or Sickness, the students should:1) Report to the Purdue University Student Health Center for treatment or referral, or

when not in school, to your Physician or Hospital.2) Mail to the address below all medical and hospital bills along with the patient's name

and insured student's name, address, student identification number and name ofthe college under which the student is insured. A Company claim form is notrequired for filing a claim.

3) File claim within 30 days of Injury or first treatment for a Sickness. Bills should bereceived by the Company within 90 days of service. Bills submitted after one yearwill not be considered for payment except in the absence of legal capacity.

The Plan is Underwritten by:UnitedHealthcare Insurance Company

Submit all Claims or Customer Service Inquiries to:UnitedHealthcare StudentResourcesP.O. Box 809025Dallas, Texas 75380-90251-888-224-4754 (dedicated Purdue line)[email protected] [email protected]

Please keep this Brochure as a general summary of the insurance. The Master Policy onfile at the University contains all of the provisions, limitations, exclusions and qualificationsof your insurance benefits, some of which may not be included in this Brochure. The MasterPolicy is the contract and will govern and control the payment of benefits.

This Brochure is based on Policy # 2012-261-3v3

PUSH Contact Information and Hours

There are representatives at PUSH (Room 338 and 340) to assist you with your studenthealth insurance needs, and to answer questions about enrollment, policy benefits andclaims.

Office Phone: (765) 496-3998Fax: (765) 496-2524Email: [email protected]

Office HoursMonday through Thursday 8:30 - 4:30Friday 9:30 - 4:30During Summer Semester and Academic breaks, PUSH is closed from 12 - 1:00PM

Office Hours - Subject to Change.Please visit the PUSH website: www.purdue.edu/push to confirm the current hours ofoperation.

PUSH

Documents

2012-261-3-Grad Staff Interim Brochure-v3 Layout 1 … · A $10 Copay for generic and $20 Copay for brand name applies to each covered prescription filled at the Purdue Pharmacy